OhioBWC - Basics:  Forms


First Report of an Injury, Occupational Disease or Death (FROI)
Use the FROI to file for workers' compensation benefits.

Health Care Finance Administration's (HCFA-1500)
A standardized form used to bill medical services.

Permanent Partial Disability Determination/Increase (C-92)
Injured workers who are permanently and partially disabled use the C-92 to file for compensation awards based on the extent of their disability.

Physician’s Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9)
Physicians use the C-9 to request medical treatments and additional conditions. Office notes supporting these requests are attached to the form, and sent to the injured worker’s managed care organization (MCO). You can complete the C-9 manually or online, and mail or fax it to the MCO. You cannot submit the C-9 electronically to the MCO.

Physician's Report of Work ABILITY (MEDCO-14)
Providers complete the MEDCO-14 is when the injured worker has been placed under work restrictions, requires accommodations, or is temporarily totally disabled.

Provider Forms
BWC has a number of forms that medical providers must complete periodically or as required by statutes, rules and policies. A list of these forms is available through BWC’s Web site, to either download or to complete electronically.